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Bad Medicine: type 2 diabetes Dr. Des Spence. British Medical Journal 03 March 2010
Type 2 diabetes is yet another "ticking time bomb." With a tripling in the rate to 6% of UK men, and with general
practitioners berated for the undiagnosed "missing million" cases, the number of people with diabetes is predicted
to double in 20 years. The rationale for detection and treatment, supported by large observational studies, is to prevent
cardiovascular and microvascular disease. This research also promotes aggressive control of glycated hemoglobin A1C, blood
pressure, and cholesterol; a mantra of "the lower the better." So people with diabetes are potentially prescribed
three drugs to control blood sugar concentrations; three drugs to control blood pressure; two drugs for cholesterol; aspirin;
ultimately insulin; and now even testosterone. Polypharmacy is the expressed state policy for diabetes, ruthlessly enforced
through national decrees. Is this good medicine? This treatment agenda is entirely dominated by drugs. Indeed the Diabetes
UK annual conference has platinum sponsorship from big drug companies, whose logos emblazon the official literature for a
mere 50,000 pounds. Also, NHS consultants are oiled by pharma's money to educate others about diabetes. Diabetes is the industry's
golden goose: a large population, lifelong treatment, and a bonanza of drugs. But polypharmacy is rarely a good idea. There
seems little research into the complications or potential interactions of a lifetime of double digit drugs. Also, the marketing
of "new drugs" exposes patients to yet unknown adverse effects, as with rosiglitazone, which paradoxically increases
the risk of cardiovascular complications. And despite having no mortality data, new drugs are widely prescribed on an unscientific
extrapolation of lowering HbAlc. This culture of targets is too restrictive, with patients reduced to little more than numbers.
Recent research shows an increase in mortality from all causes with low HbAlc and a rise in mortality again when HbAlc passes
9% (Lancet 2010;375:481-9). Other studies show a halving in cardio vascular disease in diabetes that pre-dates tight control
and a 40% age adjusted decline in diabetic renal dialysis between 1996 and 2006 in the United States (a period when dialysis
became more available) (Diabetes Care 2010;33:73-7, JAMA 2004;292:2495-9, and BM/2008;337:a236). Could the natural epidemiology
of the diabetic "time bomb" of complications be changing? If so, can the blinkered obsession with medicine by numbers
be justified? Finally, we have seen a typical disease creep of over-diagnosis, with terms like "prediabetes" and
"impaired glucose tolerance," resulting in many patients who don't have diabetes being treated as if they did. Diabetes
isn't just poor medicine for these reasons but because of the anxiety that it causes millions of people. Type 2 diabetes is
truly bad medicine because it has allowed doctors to wrap themselves in the easy comfort of a disease model, avoiding the
cold chaos of social policy to tackle obesity. It's time for doctors to advocate for health rather than be paid advocates
of big pharma. Des Spence is a general practitioner, Glasgow destwo@yahoo.co.uk Cite this as: BMJ 2010;340:c1216 . [It gets
worse, the issue is defect in collagen not high glucose that causes the comorbidity with type-2 diabetes, see link).
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